Factors influencing breast cancer screening practices among women worldwide: a systematic review of observational and qualitative studies

Background The variation in breast cancer incidence rates across different regions may reflect disparities in breast cancer screening (BCS) practices. Understanding the factors associated with these screening behaviors is crucial for identifying modifiable elements amenable to intervention. This systematic review aims to identify common factors influencing BCS behaviors among women globally. Methods Relevant papers were sourced from PubMed, Scopus, Embase, and Google Scholar. The included studies were published in English in peer-reviewed journals from January 2000 to March 2023 and investigated factors associated with BCS behaviors. Results From an initial pool of 625 articles, 34 studies (comprising 29 observational and 5 qualitative studies) with 36,043 participants were included. Factors influencing BCS behaviors were categorized into nine groups: socio-demographic factors, health status history, knowledge, perceptions, cultural factors, cues to action, motivation, self-efficacy, and social support. The quality appraisal scores of the studies ranged from average to high. Conclusions This systematic review highlights factors pivotal for policy-making at various levels of breast cancer prevention and assists health promotion professionals in designing more effective interventions to enhance BCS practices among women. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-024-03096-x.


Background
Breast cancer stands as the most commonly diagnosed cancer among women worldwide, affecting both developed and developing countries [1].Statistical analyses indicate that while wealthier nations report higher breast cancer incidence rates, less developed countries suffer from higher relative mortality rates [2].
In high-income countries, including the United Kingdom, Australia, and Eastern Europe, over 60% of women are diagnosed at stages one and two of the disease, significantly improving their survival rates.Conversely, women in low-income countries often seek treatment at advanced disease stages when it has metastasized to other organs [3].
Differences in cancer incidence rates across populations may be attributable to the variance in risk factor prevalence and the implementation or uptake of screening programs [4].
Routine screening is pivotal in detecting breast cancer at an early, more treatable stage, significantly reducing mortality rates [5].The primary methods of screening include breast self-examination (BSE), clinical breast examination (CBE) by a healthcare professional, and mammography (MMG), all of which have been demonstrated to lower mortality rates from breast cancer in various studies [6][7][8][9].
Despite numerous interventions and educational efforts aimed at promoting participation in BCS programs, recent studies indicate a continuing rise in mortality rates and a persistently low participation rate among women, particularly in less developed countries [1,10].For instance, recent figures show that only 13.6% of Malaysian, 0.3% of Egyptian, and 3.8% of Ethiopian women have undergone MMG in the past two years, compared to 81%, 88%, and 70% in Belgium, Australia, and the United States, respectively [11][12][13][14][15][16].These disparities highlight the crucial need for developing and implementing effective strategies based on scientific and reliable research to enhance screening behaviors across different societies.
Given the significance of BCS and the dire predictions that both morbidity and mortality from breast cancer will more than double by 2035 [3], it becomes imperative to conduct a comprehensive review of the published literature.This systematic review aims to [1] summarize current knowledge on factors influencing BCS behaviors and [2] identify factors relevant to enhancing screening behaviors among women worldwide.Achieving these objectives and leveraging the findings of this research could empower policymakers, researchers, and health promotion professionals to devise more effective prevention policies and interventions, thereby improving BCS behaviors through well-informed strategies.

Methods
This systematic review was registered with PROSPERO under the registration number CRD42023432810.The presentation of findings adheres to the PRISMA checklist standards (Additional file 1).

Search Strategy
The research question, structured according to the PICOS framework, was: "What are the factors impacting BCS behaviors among women worldwide?" The PICOS elements defined were as follows: • Population: Healthy individuals aged 15 years or older, encompassing all genders, races, and geographic locations.Four key search concepts and their synonyms (Table 1) were identified for the search.The international databases searched included PubMed, Scopus, Science Direct, Embase, and Google Scholar.Berenguer and Sakellariou's search strategy [17] was adopted.The search concepts, along with their synonyms (utilizing truncations and wildcards, as indicated in Tables 1 and Additional file 2), where the asterisk '*' was applied where appropriate, and subject heading terms were combined using the Boolean operators 'OR' within concepts, and ' AND' to combine concepts, thus developing the final search strategy (Additional file 2).

Inclusion and exclusion criteria
Studies were included if they:

Study selection
The selection followed PRISMA guidelines.Initially, duplicates across databases were removed.Titles and abstracts were then reviewed for relevance, and articles not meeting the inclusion criteria were discarded.Subsequently, full texts of the remaining studies were evaluated for relevance, with any further non-compliant studies excluded.This review process was independently conducted by two researchers, with any discrepancies resolved through discussion.

Quality assessment
Following numerous academics' recommendations, the methodological quality of the included studies was assessed, and a Methodological Quality Score (MQS) was assigned.Experts evaluated each study's conceptual and methodological rigor, resolving discrepancies by consensus.Based on Bernstein's standards [18] and as explained by Patton [19], the assessment criteria included theoretical framework usage, study design, sample size, measurement instruments, data analysis, and reporting on reliability and validity.Quantitative studies were scored on a scale from 0 to 19, and qualitative studies from 0 to 14, with higher scores indicating higher methodological quality.Studies scoring below 60% were excluded.

Data extraction and synthesis
Data were independently extracted by two researchers (BT and HSH), using a pre-designed tool to collect methodological details, including first author, publication year, study design, data source, study location, sampling strategy, sample size, data collection techniques, participant age, BCS method, and conceptual framework.For quantitative studies, additional data on screening participation rates and identified factors associated with BCS behaviors were noted.Qualitative studies included thematic information extracted for analysis.

Results
An initial search yielded 625 articles from the specified databases.After removing duplicates and screening titles and abstracts, 118 papers were selected for full-text evaluation.Ultimately, 34 papers comprising 29 observational studies and 5 qualitative studies, with 36,043 participants, were included in the final review.The study selection process is illustrated in Fig. 1.

Quality of included studies
None of the studies achieved the highest possible score.
A majority of the studies were cross-sectional designs (82.4%), and over half (64.7%) included large samples (more than 300 participants).Furthermore, 67.7% of the studies grounded their findings in specific theoretical frameworks.Approximately half reported the psychometric properties of their assessment instruments.A significant portion (85.3%, N = 29) of the studies were quantitative and utilized both descriptive and advanced statistical analyses, such as t-tests, multiple regression, logistic regression, and multivariate analysis.The qualitative studies (14.7%, N = 5) primarily employed content and thematic analysis.All quantitative studies assessed the statistical significance of factors associated with BCS behaviors (Table 2).

Factors associated with BCS behaviors
The question of "What factors impact BCS behaviors in women worldwide?" is comprehensively answered through the analysis presented in Tables 4, 5 and 6.These tables delineate the factors influencing BSE, CBE, and MMG, respectively, as identified in the 34 reviewed articles.
The factors identified are categorized into nine key areas: 1. Socio-demographic Factors: This includes age, education level, income, marital status, and employment status, highlighting how these variables influence screening behaviors.2. Health History: Past health experiences, family history of breast cancer, and personal health beliefs play a significant role in an individual's decision to undergo screening.3. Knowledge: The awareness and understanding of breast cancer and the benefits of early detection through screening methods.4. Perceptions: Women's beliefs and attitudes towards breast cancer risk, the effectiveness of screening, and the healthcare system's role in cancer detection.5. Cultural Factors: How cultural beliefs, norms, and societal expectations shape attitudes towards breast health and screening practices.
Table 2 Criteria for methodological quality assessment of reviewed studies and the frequency distributions of each criterion

Theoretical Framework
The study had no theory = 0 points 32.3 The study was based on a specific theory = 2 points 67.7

Discussion
The primary goal of this study was to identify the universal factors influencing BCS behaviors among women globally.Although most countries offer BCS programs [17], the nature and implementation of these programs vary significantly across different health systems and populations [49].Consequently, the BCS methods examined in this review varied, reflecting these disparities.MMG, recognized for its efficacy in clinical studies, is predominantly used in developed countries due to its higher costs [8].Conversely, in developing countries, BSE stands out as a widely adopted, cost-effective method for early detection [50].Moreover, the rates of screening methods reported in the literature show considerable international variation.Countries like Sweden, Belgium, the USA, and Australia report high MMG screening rates [14][15][16]43], whereas BSE is more prevalent in countries like Egypt, Ethiopia, Turkey, Iran, and Iraq [12,13,25,26,32], often falling below the WHO's recommended screening rates [49].
The WHO underscores the importance of high participation rates in screening programs to enhance their effectiveness [49].Understanding the factors influencing participation enables health systems to adopt comprehensive strategies for prevention, early diagnosis, and BCS promotion.
Over half of the studies reviewed focused on sociodemographic factors as determinants of screening behaviors, identified in previous research as facilitators and barriers [51,52].Findings indicate that demographic variables such as age, education level, income, and employment status significantly influence screening rates.
While socio-demographic status is recognized as a crucial determinant of access to BCS in both highincome [51,52] and middle-income countries [10,17], studies in European countries with organized screening programs report no correlation between screening participation and socio-demographic variables [53].A 2011 study exploring the impact of socioeconomic inequalities on screening participation highlighted that such disparities exist even without financial barriers [54].These variations necessitate careful interpretation, considering women's diverse challenges in accessing screening services worldwide, including geographical, economic, and cultural obstacles.
For instance, despite Qatar's provision of comprehensive medical services at no cost, including BCS, cultural barriers have led to only a third of eligible women utilizing these services [34].Thus, offering organized screening programs with equitable access could gradually mitigate socioeconomic disparities.
The review also highlights that beyond a family history of breast cancer and personal breast health issues, fertility-related challenges, such as infertility and hormonal imbalances, influence screening behaviors.This finding aligns with systematic reviews from China and the USA, which examined screening factors among different populations [55,56].Women with personal or familial health histories may perceive a higher susceptibility to breast cancer, thereby increasing their utilization of healthcare services for screening and diagnostic tests.This heightened awareness and concern about breast cancer risk can motivate women to adopt preventive measures, including screening.However, it is notable that many women may  Employment status [13,20] Income [11,13,20] Marital status None

Number of Children None
Ethnicity None

Region of Residence None
Race None Spouse Demographic Characteristics [13] [20]

None
Hearing About BC and BCS from Health Team or in the Media [22] Similarly, Reminder Letters, Phone Calls, or Text Messages

Motivation
High Level of Hope and Health Motivation for the Future [30, 36] [29] not pursue screening until symptomatic or following the discovery of breast cancer in close relatives [57,58].
The findings of the study reveal that women with comprehensive knowledge about breast cancer risk factors, symptoms, and screening methods are more likely to participate in screening programs.Conversely, women who have not undergone screening often lack awareness or believe that once screened, repeat screenings are unnecessary [59].This lack of knowledge has been identified as a critical barrier to screening participation among Iranian and Asian women and as a predictive factor for the late diagnosis of breast cancer in Canada [10,60,61].However, Schlueter's study found no correlation between the level of knowledge and screening behaviors [62], indicating the complexity of this relationship.
Educational interventions targeting breast cancer awareness and screening guidelines are crucial for improving women's knowledge and participation rates.
Types of fear recognized include the fear of mastectomy, diagnosis of cancer, and stigmatization [34,46,48].Consedine et al. noted that while fear of cancer could facilitate screening, specific fears-such as those associated with medical procedures or diagnosis-often deter women from participating [64].A meta-analysis further linked fear of breast cancer to screening behaviors [65], suggesting that mitigating fear through education and positive screening experiences could enhance participation rates.
Cultural factors, particularly religious beliefs, and fatalism, notably impact screening behaviors.Some Muslim women believe BCS is unnecessary, viewing cancer as a divine challenge or part of destiny [63].This fatalistic view, a belief in the health locus of control being external (chance or divine will), can lead to passive health behaviors [66].While some studies show no significant impact of religious beliefs on screening behaviors [67], the intertwined nature of these beliefs with culture and religion necessitates nuanced interventions.
Effective strategies might involve integrating breast cancer awareness and early diagnosis information within the framework of existing belief systems leveraging religious leaders to promote health messages aligned with spiritual teachings.Such approaches, using religious and spiritual elements in health messaging, have been shown to encourage screening behaviors among women [11].

Cues to Action
Breast Cancer Screening by Family Members and Friends [40,42] Hearing About BC and BCS from Health Team or in the Media [22, 27, 42] [11] Similarly, Reminder Letters, Phone Calls, or Text Messages [42] Motivation High Level of Hope and Health Motivation for the Future [30] [29, 48] In the modern era, widespread access to information through digital media, advancements in technology, and the introduction of electronic health tools have facilitated the use of these platforms in cancer screening campaigns.For instance, smartphone applications that remind users about screening schedules and provide preventive advice through text, images, and videos represent an innovative approach to enhancing screening participation.
This review also underscores a significant link between motivation and BCS behaviors.Khazaee-Pool et al. found that motivational solid factors, such as valuing life and health responsibility, significantly encourage screening participation [21].Moreover, studies among diverse racial and ethnic groups have identified a clear association between motivation and increased screening activities [70].
Various socio-psychological barriers, including attitudes, cultural beliefs, and communication issues, have been identified as impediments to motivation [71].Factors contributing to low motivation for MMG include the perceived unimportance of testing, lack of support, time constraints, cost concerns, familial obligations, and a busy lifestyle [48].Therefore, interventions aimed at enhancing motivational self-efficacy could significantly improve screening participation.
As part of self-care practices, regular health check-ups have been shown to predict screening behaviors.Reviews have highlighted a correlation between infrequent mammograms and breast exams among Asian and Korean-American women with irregular gynecological visits [51,59].Although MMG can be performed without direct referrals in some countries [59], the lack of commitment to regular check-ups remains a barrier.As Pasket et al. reported, while 75% of women acknowledged the importance of periodic exams, 67% indicated that their physicians did not actively encourage MMG [72].
Improving knowledge about self-care and self-regulation is crucial for fostering regular health examination habits.The health system's role in scheduling periodic health assessments and encouraging adherence is also vital, as demonstrated by research from the Netherlands, which linked pre-scheduled appointments and proactive general practitioner involvement to higher screening rates [49].
Regarding social support, assistance from healthcare teams and family members significantly influences screening behaviors.Lack of partner support and fear of familial disruption post-diagnosis have been noted as significant barriers among African-American women [68].Support from family and friends, providing both financial and emotional backing, can bolster confidence, reduce fear, and encourage screening participation [21,59,73].
The review also points out that women's financial independence and employment status in certain regions are critical in health decision-making.Conversely, many women rely on male family members to make health decisions, a group that requires targeted support from health teams for emotional, instrumental, and informational needs.Leong et al. found that social support not only reduces depression but also promotes healthier behaviors [74].Thus, establishing support networks and self-help groups can enhance women's knowledge, experience, and motivation regarding BCS, ultimately fostering a community of mutual encouragement and support.

Strengths
This systematic review meticulously evaluated the quality of included studies to ensure their reliability and

Studies displaying no association
Qualitative studies

Limitations
This research was confined to online studies, potentially overlooking valuable research indexed in databases such as PubMed, Scopus, Embase, and Google Scholar or available only in print.The restriction to English-language publications may have excluded pertinent non-English studies, introducing language bias.The review's predominance of cross-sectional studies limits the ability to ascertain causal relationships between the factors studied and screening behaviors.Additionally, the reliance on self-reported data raises concerns about the accuracy of the findings, given the potential for recall bias or the desire of participants to present themselves in a socially desirable light.The heterogeneity of the included studies-in terms of study design, geographic location, methodological approach, demographic characteristics, sample size, screening methods employed, and the intervals between screenings-complicates direct comparisons and may affect the generalizability of the findings.

Conclusion
This systematic review synthesizes a broad array of research on the factors influencing BCS behaviors among women worldwide.By examining various screening methods and participation rates, along with identifying determinants of screening behavior, this study contributes valuable insights to the field of public health.The findings highlight the complex interplay of factors affecting screening behaviors and provide evidence-based guidance for policymakers and health promotion professionals.This knowledge is crucial for developing targeted interventions that can effectively encourage BCS practices, ultimately contributing to breast cancer prevention and early detection.

Factors
Associated with BC Screening No factors were identified = 0 points Uncontrolled analysis (factors were not tested for statistical significance)

Table 1
Search key terms achieved from the research question *Some letters have been added to these words in the search time

Table 3
Summary of the characteristics of included studies reviewed Abbreviations: BCS Breast cancer screening, BSE Breast self-examination, CBE Clinical breast examination, MMG Mammography, MQS Methodological quality score

Table 4
Identified factors associated with breast self-examination behaviors among women around the world in the 34 reviewed articles

Table 5
Identified factors associated with clinical breast examination behaviors among women around the world in the 34 reviewed articles

Table 6
Identified factors associated with mammography behaviors among women around the world in the 34 reviewed articles